— and — A Short Written Message: Improved Satisfaction After Withdrawal of Life Support

Abstract & Commentary

By Leslie A. Hoffman, RN, PHD, Department of Acute/Tertiary Care School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.

Dr. Hoffman reports no financial relationship to this field of study.

Synopsis: Families who received written information about withdrawal of life support felt more prepared and were more satisfied when contacted 2-4 weeks later.

Source: Kirchhoff KT, et al. Preparing families of intensive care patients for withdrawal of life support: A pilot study. Am J Crit Care 2008;17:113-121.

The need to prepare families for withdrawal of life support is well known. However, the specific information needed to accomplish this goal is not well defined. In this study, 22 participants were randomized to receive a brochure with information about what to expect during withdrawal of life support, or to usual care without receiving the brochure. The brochure was provided in one of four versions. Each version of the brochure had three parts. An initial generic part included information about the uncertainty of the time interval until death, assurance that comfort measures would continue, and general information about what to expect in regard to physiological changes, e.g., breathing, skin color, and movement. The second part included additional information about anticipated physiological changes with different text depending on whether the patient would remain intubated and the anticipated duration of time before death. A final generic part provided information on actions family members could choose to take, e.g., touching, talking, and remaining with the patient.

When contacted by telephone 2-4 weeks later, families in the intervention group expressed greater satisfaction with the information they were provided (P < 0.05) and their understanding of how death was likely to occur (P = 0.03). The usual care group reported having to ask for information, not being prepared, and not understanding that time to death can differ among patients.

Commentary

ICU clinicians recognize the need to prepare families for the withdrawal of life support. A variety of studies have identified that this information should address how treatments will be withdrawn, that comfort will be ensured, how long the patient is expected to survive, and how the team will continue to provide care. Often, such information is provided in a family conference with follow-up at the bedside.

The present study had three unique features. First, information was provided in writing, as well as verbally. During this emotional experience, it is easy to forget details about the information shared. Having information available in a pamphlet appeared to provide additional support. Second, the information provided was specific with regard to what might be expected including changes in breathing, skin color, etc., and individualized as to whether patients were intubated during the process. Third, the information gave permission to show emotion, talk to, and touch the patient. Rather than being emotion-provoking, the detail proved comforting based on questionnaire responses and additional unsolicited comments.

The distress surrounding such events can be profound. Siegel and colleagues interviewed the next of kin of 51 patients who died in an ICU in a university teaching hospital, and reported that 34% of these individuals met criteria for at least one psychiatric illness, including a major depressive disorder (27%), anxiety disorder (10%), panic disorder (10%), or complicated grief disorder (5%).1 Most participants considered the health care team to be compassionate and clear in their explanations, suggesting that communication occurred commonly and was well received. The additional step of providing a brochure, tailored to circumstances expected during withdrawal of life support, is a simple but important means of potentially decreasing grief and depression after the event.

Reference

  1. Siegel MD, et al. Psychiatric illness in the next of kin of patients who die in the intensive care unit. Crit Care Med 2008;36:1722-1728.